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POSTOPERATIVE COMPLICATIONS. Samaad Malik, MD, MSc, FRCSC Clinical Fellow, CMAS McMaster University August 20, 2008. Objectives. Case Based Clinical Approach Examination Preparation. POS Question sample. 1. What enzyme facilitates access of snake venom into the human lymphatics?
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POSTOPERATIVE COMPLICATIONS Samaad Malik, MD, MSc, FRCSC Clinical Fellow, CMAS McMaster University August 20, 2008
Objectives • Case Based • Clinical Approach • Examination Preparation
POS Question sample • 1. What enzyme facilitates access of snake venom into the human lymphatics? • Hyaluronidase • Peroxidase • Acethycholinesterase • Crotalase
We shall not cease from exploration And the end of all our exploring Will be to arrive where we started And know the place for the first time. T.S. Eliot
Surgical Complications • Surgical Wound Complications • Complications of Thermal Regulation • Pulmonary Complications • Cardiac Complications • Renal and Urinary Tract Complications • Endocrine Complications • Gastrointestinal Complications • Hepatobiliary Complications • Neurologic Complications • Ear, Nose, and Throat Complications
Approach • Page • Elevator thoughts • Quick Bedside Look • ABC • Selective H+P • Management
Case • 85 yo elderly male • POD #3 Laparoscopic Colectomy • Painful R cheek while eating
What are your thoughts? • Diagnosis • How do you want to proceed?? • Treatment
Parotitis • Decrease in the secretory activity of the gland with inspissation of parotid secretions that become infected by staphylococci or gram-negative bacteria from the oral cavity
Parotitis • Potentially serious • Elderly • Poor oral hygiene • Poor nutritional state • Dehydration
Post operative Parotitis • Results in inflammation, accumulation of cells that obstruct large and medium-sized ducts, and, eventually, formation of multiple small abscesses • These lobular abscesses, separated by fibrous bands, may dissect through the capsule and spread to the periglandular tissues to involve the auditory canal, the superficial skin, and the neck • If the disease is not treated at this stage, it may produce acute respiratory failure from tracheal obstruction
Diagnosis • Clinical • Pain or tenderness at the angle of the jaw • Swelling and redness in the parotid area • High fever and leukocytosis develop • Investigations • Ultrasound
Treatment • Clindamycin/Vancomycin should be started while the results of cultures are awaited • Warm moist packs and mouth irrigations may be helpful • Rehydrate
Case • 68 yo male • POD #1 Lap APR • Desaturated to 85% • What are your thoughts?
Case • Approach • ABC • Hx and Px • Investigations • Bloodwork • CEA • Consultation
Thromboembolisms • Mechanisms: • Alterations in normal blood flow • Injuries to vascular endothelium • Alterations in the constitution of blood
Symptoms and Signs of Pulmonary Embolism • Pleuritic chest pain[*] • Sudden Dyspnea[*] • Tachypnea • Hemoptysis[*] • Tachycardia[*] • Leg swelling[*] • Pain on palpation of the leg[*] • Acute right ventricular dysfunction • Hypoxia • Fourth heart sound[*] • Loud second pulmonary sound[*] • Inspiratory crackles[*]
Investigations • CXR, ECG, ABG • D-dimer • CT scan • V/Q scan • Duplex U/S • Pulmonary Angiogram • Echo
Treatment • Depends on hemodynamic stability • Unstable • Get help • Thrombolytics? • Stable • Anticoagulate • intrinsic fibrinolysis restores pulmonary blood flow
Heparin • Complications • BLEEDING • osteoporosis • HIT • No increased risk of bleed • INCREASED risk of Thrombosis • BOTH ARTERIAL AND VENOUS • Increased for a period of 1 month
Heparin • Prevents formation of new thrombi and stops propagation of thrombi • Enhances antithrombotic activity of antithrombin III • Contraindications • Consider IVC filter • Overt bleeding
HIT • can occur with LMWH as well • Usually after 5-10 days
HIT • Treatment • Get help – Hematology • Discontinue Heparin • Other anticouagulants • Argatroban • Danaparoid
IVC Filter placement • Indications • Recurrent PE despite adequate anticoagulation • Contraindications to anticoagulation
DVT • Investigations • presentations • management • medical
Mortality no h/o MI 1-1.2% 6 or more months 6% 3 months 16-37% age more than 70 AS medical conditions emergency operations Intraoperative hypotension Preoperative CHF Preoperative Hypotension Angina Cardiac
Cardiac Pearls • Inpatient HR 101 • Intravascular volume depletion till proven otherwise • Pain • Fever
Case • 67 yo female • POD #3, Ivor Lewis Esophagectomy • HR= 168 • BP= 80/60 • What to do next?
Approach • ABC • ACLS protocol • Call for help!!
Catch! • Cardiac Arrythmias • Underlying cause • Extracardiac – sepsis • Anastomotic leak
Pulmonary • Smoking • Obesity • Age • Home oxygen • Unable to walk 1 flight of stairs w/o respiratory compromise • Major lung resection • Screen with PFTs, CXR
PFT’s • Studies demonstrate that any patient with an FEV1 greater than 2 L will probably not have serious pulmonary problems • Conversely, patients with an FEV1 less than 50% of the predicted value will probably have exertional dyspnea.
Ventilator • Criteria for Weaning From the Ventilator • Respiratory rate<25 breaths/min • Pao2 >70 mm Hg (Fio2 of 40%) • PaCo2 <45 mm Hg • Minute ventilation 8-9 L/min • Tidal volume 5-6 mL/kg • Negative inspiratory force- 25 cm H2O
Case • POD #4, Whipple’s • Temp, fever • CXR shows collapse consolidation of RLL consistent with pneumonia • Treat?
Community-acquired pneumonia (CAP) • infection that begins outside of the hospital • is diagnosed within 48 h after admission to the hospital in a patient who has not resided in a long-term facility for 14 days or more before the onset of symptoms
Hospital-acquired pneumonia (HAP) • infection of lung parenchyma occurring more than 48 h after admission to a hospital
Empiric Therapy • HAP • Cefotaxime+ gentamycin • Tazocin • CAP • Fluoroquinolones • Levofloxacin • Macrolides • azithromax
Postop Fever • Courtesy of Diagnosaurus • Wind: pneumonia, atelectasis • Water: urinary tract infection • Wound: wound infection • Superficial vs deep • Walking: deep vein thrombosis (DVT) from immobilization • Wonderdrugs: drug fever • Wanes: CVL, peripheral lines
Postop Fever • Tubes: N/G • sinusitis • Surgery: anastomosis • Spinal: epidural abscess • Cardiac – Endocarditis • Colorectal: perianal abscess • HPB – acalalculous cholecystitis
Acute Renal Failure • Defined as urine output <25cc/hr, increasing Cr, increasing BUN • Associated mortality, >50% • Differential dx • Prerenal • Renal • Post renal
Thyroid Storm • Thyrotoxic crisis • Acute life threatening exacerbation of thyrotoxicosis • Usually in patient with discontinued antithyroid medication or more commonly undiagnosed hyperthyroidism
Thyroid Storm • Clinical • Acute onset hyperpyrexia (temp>40 ‘C) • Diaphoretic • Marked tachycardia (Afib) • Nausea, vomiting • Agitation • Delirium • Tremulousness
Thyroid Storm • Precipitants: • Surgery • DKA • Sepsis • MI • Trauma • Drugs • Iodinated contrast
Thyroid Storm • Diagnosis • Serum T4, T3, free T4, free T3 elevated • TSH suppressed
Thyroid Storm • Treatment • ABC • Get help – Endocrinology/Medicine, ICU • Treat the underlying cause • Specific • Propanalol • Propylthiouracil • Methimazole • KI • Steroids?
Take Home Messages • Clinical: • Have a good approach to common clinical scenarios • Acknowledge your limitations • Do not hesitate to access multidisciplinary approach
Take Home Messages • Examination • DO NOT READ SCHWARTZ from beginning to end • Old exams